MCHB/DHSPS April, 2008 Webcast

Care Coordination Reform: Connecting at Risk to Care

April 15, 2008

>> Good morning. On behalf of the division, I would like to welcome you to this web cast entitled "care coordination reform, connecting at risk to care." Before I introduce our presenters toe, I would like to make some technical comments. Slides should advance automatically. They will synchronize with the presentation. You do not need to do anything to advance the slide. You may need to adjust the timing of the slide to match the audio by using the slide delay control at the top of the messaging window.

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Today we have two presenters. First is Dr. Mark Redding, who is the medical director of the community health access project. Following him will be Rick Wilk, the director of the Chicago office of performances youth who will be making a few comments following Dr. Redding's presentation. In order to allow ample time for the presentation, we will refer questions and answers -- the question and answer session to follow the presentation. However, we do encourage you to submit questions via email any time during the presentation. Please identify which speaker the question is for. We would like to welcome the speakers and audience and begin the presentation. Dr. Redding?

MARK REDDING: Thank you. Thank you all for being part of this web cast and the technical distance folks have had to give me a lot of directions which I don't know if I'll be able to follow but I'll do my best. What I hope we will accomplish today is to present to you basically some ideas, certainly we don't have it figured out but some ideas, concepts, strategies you might be able to use and I think what we would also like to accomplish is present to you a challenge. And not only to you who are within community programs and providing the service but also to those of you providing support and funding and policy work related to this. To kind of highlight that I know I don't have it all figured out, I would like to tell you a quick personal story.

My wife is a physician as well and we work together in this work towards helping connect at risk people to care. And she travels and she was leaving for a particularly long trip several months ago and was going to be gone five or six days. My little boy, the night before she was leaving, he ran to her room and asked if everything was in his star wars book bag because he's particular about everything being in there in the morning. She said, well, David, your father is going to be in charge while I'm gone. You go ask him. And so he did. And I said, well, Dave, what goes in your star wars book bag? And he made an awfully sad face and left the room and later on that evening, he had a heart to heart with his mother and he said, mom, if anything ever happens to you, he's going to have to get remarried right away. So with that, realizing we're all human beings and all have our own role, next slide, please.

I would like to challenge you and discuss with you a particular dilemma and crisis that I believe exists within our health and social service system. Starting this presentation with the end of it in mind, what we believe needs to happen is that we need to find the people who are at risk. At risk for health, social, educational, behavioral health conditions. We need to assure that they are treated and treated with evidence based intervention treatment that has a basis for working and we need to measure our results and do that faster and better and smarter. What I will present, those most at risk and I've been involved in this work more than 20 years now. They're in the back of trailers, back in the dangerous urban housing complexes. They represent the greatest waste of our health disparity our nation and we are not reaching them and we are not connecting them to care. And I would ask how could we have the most extensive health care system in the developed world and not reach those that need the services the most? So possibly simplicity can help us in this highly complex system of ours. I'm not very good at it and it's taken a lot of work to help focus in that area but trying to find simplicity, how do we organize this? One way of looking at it, and we can throw this out at the end of the presentation. One way to organize it is to find and connect to care can be seen as care coordination and it's defined in the latest academy of pediatrics policy statement as essentially the work that happens outside of the -- between the doctor's office waiting room or the hospital waiting room and the person's home. And it is a part of the system that in many ways, especially quality we have ignored. So that part of the system, the finding the person and connecting them to care is the focus of this potential reform effort. The direct services, that's the cat scan, the lab test, the doctor's visits, the diabetes followup, hemoglobin, you name it. The final step is improvement as we move forward. So one way just to help the conversation is to say that the health and social service system has direct service component and has a care coordination component and obviously they are interwoven but there are advantages to breaking it out this way. I think the other thing you'll find in this discussion is an individual based approach. And this is not to recognize the very important intervention of population based health policy. In other words, not smoking in restaurants and fluoride in the water and safer sidewalks, absolutely, we need that. But we also need to make sure we do good individualized assessment and intervention. As a pediatrician, it would be great to go in the waiting room and serve a particular type of cookie or spray something in the air and everybody out there would be OK but that's not how it works. It's actually only through careful assessment and identification of the evidence based packages that people need that healing can be realized in that setting. So how -- essentially care coordination has been termed social work. It's the part of the health care system that us doctors have not been interested in. We're more interested in our 10 to 15 minute visit. How did I get interested in it? My grandfather had been a missionary. I wanted to be one, too. My wife and I headed for Alaska off the Bering Sea. Wonderful place to be a missionary. 70 degrees below zero in the wintertime. Most of our -- many of our patients lived in plywood shacks. Record rates of alcohol abuse and other determinants of health. Alaska in the last ranking of maternal child health indicators had the lowest birth rate of any of the states. What does Alaska have? Not only for pregnancy but for all of the diseases and again, I hope you'll keep your mind open in this discussion. What does Alaska have? What they have is that a system that within each at-risk Eskimo village already individuals part of the community and if you're 16 and pregnant or you're 52 and you have diabetes, they know and they're at your door and you'd better believe you're receiving health care. If you don't, they know your cousin and aunt and everybody else and in an exciting way, they're not in isolation. They are linked to nurses, doctors, social workers and in our work in Ohio, we have definitely found social workers and nurses that are also able to do this same work. But they had a way to find those at risk and connect them to care. Alaska not only had this at the community level but a delivery system approach. And they -- it exists today with over 500 community health workers across the state. The system was invented with the port of the agency whose building I sit within today but -- and so this promotes standard measures of quality, standard training, standard everything with the ability also for each community to have their own individualized approach to doing other parts of this. My wife and I moved from Alaska to Baltimore after three years there and my wife Sara bumped into an elderly gentleman in one of the old lecture hall there is at Hopkins and it turned out to be a doctor who worked with public health nurses to build Alaska's first system. He helped us get our first community health worker and outreach program going in Baltimore and he died about a year ago and this was the quote on the cover of his statement. If you want to be a missionary, the lower 48 of the United States is a great place to start. I think we should take pride in the fact that although it was close, we did beat them this last time. We were otherwise at the bottom of the developed world for basic health care outcomes.

Next slide. I think we can also take pride in the fact that we spent more than any other developed nation and this slide is a little out of date because the situation is much worse now and ranked us against the five countries with the best basic outcomes for health. I think what is particularly disturbing about this slide is if all of that money we're spending purchases goods and services to have an impact on health, and we're spending twice as much of it as any other nation in the developed world and we have the worst results, where is the money coming from? And sadly, it's coming from American business which is very accountable for its products and services and cannot afford this expenditure from the waitress to the private business leader who is moving his company overseas, substantially related to the cost of health care. And it does not obviously point to something that needs to be tweaked or adjusted but fundamental change. Albert Einstein said we can't solve today's problems by using the same kind of thinking we used when we created them. We've created a pretty big problem and I don't think it points to any one agency. It's from the information and from the way we're looking at it, it points to all of us. We're each involved. We're each part of it. I would like to highlight, for example, Medicaid which is just one of all of us but the cost per Medicaid has tripled in just a little bit more than 10 years. Basic outcomes in my state are worse than they've been in 20 years. Something is wrong. So let's look at the fundamental basic components of our system. Is it the treatment services that are bad? You know, I have no idea there are some bad but in general, we have the best evidence based interventions in the world. We have diabetes intervention, cardiac intervention, obesity education, prenatal care, people fly in from all over the world. These interventions are benefiting substantially our wealthy population. They simply are not -- these packages of evidence based care are simply not connecting to those who need it the most. I would like to just highlight one example so that -- to make sure you're thinking is broad enough in this category. The Australians have developed an education packaging for parenting called triple peace. You go to a course and you get the materials and you become a triple t provider. What is interesting about it is I take the same course that a community health care worker would take, a counselor would take. Once you've taken the course you deliver this package of parenting education to parents that teaches them to handle discipline correctly but to primarily focus on their child's strength and what's great about that child. Substantial improvement in school performance, close to 50%. Substantial reduction in ADHD. Possible until terms of long-term outcome for everything from employment to some of the neighborhoods we work in with more than 50% of males going to prison, imagine what this kind of evidence based intervention delivered to families in a culturally appropriate way could do and it's certainly helped me as I have struggled with my own similar situation says. So we have the packages. Realizing the care coordination is much more complex than this, but looking at it like Fed Ex, we have the packages of evidence based intervention. There's no need -- I mean, I'm not saying not to continue research but we have a lot of research showing what works, what doesn't work. What we need to focus on is like Fed Ex, making sure that everybody, not just the wealthy, get the packages. So this is just a small low scale intervention which is one of many and there are many and I want to mention, for example, Mario German's program was in the healthy start program. It was far greater than what I have to present to you here but I'm going to use this as an example. In our own county, we were told that there really wasn't a problem with low birth weight because it was about the same as the state average but then you have to remember that we're the worst in the developed world to put that into context and then you have to remember that my wife got pretty fired up about that and she got every birth certificate in the county for five years and plotted it. And we found census tracks in our own county where low birth rate was actually approaching 24%. And they were within the most impoverished. We know where the most at risk are. This part of it is a piece of cake. We identified individuals from part of the community. We trained them with college credit. I've brought some of our training materials. There are many other such examples across the country. We support them with nurses and physician backup and next slide, please.

They reach out from a central community setting. These individuals know 40 to 60% of the families before they even knock on the door and it is in the center of the little blue dots that you saw on the previous page. We thought we would teach them a great deal but actually, the teaching happened far greater on their teaching us. What they taught us was even though that center is just a few miles from the office, it's more than a few hours by bus. You're traveling there on a cold day or a hot day with a bunch of kids and the buses or the transfer runs late. At not only my own office but nine others, if you're 15 minutes late, we send you home. We need to teach these people responsibility, it's said. Just another on the ground example of us rich people or wealthier people trying to teach other people something when we have no idea of the context in which they come from and what they're struggling against. These are not the only barriers that our community health workers taught us. If you have a 17-year-old and she's pregnant and she lives in the back of a housing complex with no phone, with a little card table and an eviction notice on the table and another small child to look after and it's March, her prenatal visit probably isn't her number one priority. Those of us who built the system do not have the context and we need this wisdom. We began addressing housing and food and clothing and partnered with close to 40 churches now in this area to help provide for those issues. The other partners we've developed and I think this is also a new partner in these kind of initiatives is American business. A gentleman named Samuel Starr who we caught between jobs as a volunteer but who later was in Forbes magazine for redesigning sterling commerce as a global internet consultant and software provider told us that if we were going to have a program that provided an intervention, we first needed to very carefully define what it was we were going to do and how it would be meaningful to our customers. And what he identified was that in our current system, what we produced was a number of visits, number of charts, number of progress notes, none of which have any meaning to the person served. So we developed a model that just mirrors American business and it captures the steps that again are meaningful to the client and they, again, this is all focused within care coordination. I am not here to promote this model anymore than I'm definitely here to promote that in care coordination, you need to define what is meaningful to the person you serve and make sure you do that. And I brought some of these pathway cards and they're also on our website but this is the kind of thing that our care coordinators carry around and live and breathe by. There are over 40 of these pathways in production not only in our agency but approaching 100 other agencies and the way this kind of thing can fit into your own care coordination approach is -- I'm sure most care coordination programs do an assessment and ours is several pages long. It's health, mental health, social issues, behavioral health and others. But where that landed prior was those issues identified within our plan of care. Where they land now is if you're homeless, you're on a homeless pathway and we've got key benchmarks to make sure you get basic education, that you're confirmed to connect to housing and the pathway ends with a specific result and so housing is an example. You would not complete the pathway until the person had secured housing. If the pathway is pregnancy, the at-risk person is identified, they're provided evidence based education related to pregnancy, their barriers are understood and it is not done until they have been confirmed to connect to prenatal care and finally have delivered a baby that is greater than five pounds, eight ounces. So it's a structure where you can build what you think is meaningful and you can construct the outcomes or the results that you want to achieve and then each client may have -- our most at-risk clients may have 30 of these pathways dealing with health and social issues and in each case if you consider our second slide of finding at risk, treating the at-risk person and measuring the result, we are in each pathway identifying the problem, ensuring that they connect to something meaningful to address that problem and we're measuring the result. What we found on implementing this exciting model was unfortunately we weren't producing very many of these. We had been previously able to impress our funders with a number of clients, a number of services, all of the different things we were doing but when it really came to producing these results, we had very few. We again hooked up with our American business colleagues and what we did, interestingly, that had the most substantial effect was we began to tie our own contracting to the achievement of these results. And we began to tie our employees' incentives to achieving these results. So Juanita, one of our top performing community health workers in Ohio, can do -- she makes a very impressive salary but she can get 20% more salary based on these results. If you're pregnant, she knows it and she's now doing as well almost as our nurse because of her outstanding performance in finding at-risk and connecting to care. The other interesting thing is our own program and others through this financial driver have substantially -- has substantially improved how many people we're finding and connecting to care because of the financial accountability. I'll take a technical second with you here.

The next slide shows our rate of low birth rate reduction. In census tracks where low birth rate was over 20% for enrolled clients, we began, over time, to see a low birth weight rate less than 5%. This has not been compared to an adequate control group, although in collaborating with other researchers we've been told it's the most at-risk population of pregnant women they've ever seen in terms of other risk factors like smoking and previous pre-term infants and others. But this, although in so many ways this is a critical slide and the outcomes for our patients are what we want to achieve, it's actually not the most important part of what I have to present to you today because obviously, if we connect people to evidence based interventions that they need, they're going to have better results. So what is most important about the presentation today is not the fact that we have achieved better health outcomes, others have done that far better than we have done in a research perspective. What we have done and what is represented in this presentation and by we, it's a pretty far stretch. Other partners across the United States. What is happening with this is within care coordination, we're defining specific meaningful work products to the individuals we serve and we're beginning to deliver them not only in our own agencies but across a community structure. The opportunity for care coordination to reform, I believe in my heart of hearts is the lowest hanging fruit for health care reform in this upcoming political season. The strength of our system in part is that we do have excellent -- and I know they vary but evidence based interventions. They are defined and packaged and have basic indicators and they have a price and a cost. If we drive the costs down further, I believe there will be a further rebellion of the provider systems to even provide care within the system that's been built. There's no doubt that it needs work. But on the care coordination side, the way that is funded is in pools of funding. You can't even see the cost per person, let alone the cost for the specific product that are served. You cannot see how it affects the person and it is not yet -- it has not yet achieved the definition that it is about the people served because most of the money is not going to things that are meaningful to the people served. It's going, unfortunately, to things that are meaningful to the system itself. To define what we mean by meaningful, if you examine in state contracts and the federal legislation itself, all of that represents a request, a requirement. It represents a purchase of a work product and the work products that are being purchased are meaningful. The most common work product purchased today in the health care system and we're focusing on care coordination, you're on a list. If you're an agency, you find the client, enroll them, do the assessment, they're on the list and you submit that list on a monthly basis and you are paid. That individual may not even know who you are. They may have just gotten something in the mail or a phone call. Nothing meaningful has happened to them. More rigorous programs require a phone call or a chart note or document the amount of time that somebody might spend. But except in specific locations, the work products purchased in care coordination do not have a basis for meaning to the client. What is exciting about the opportunity, it's pretty easy to define the benchmarks of work products and care coordination that could be meaningful like the person actually connected to care. Or they connected to other supportive services that address the other determinants of the -- the social determinants of health like education, clothing, even employment. There is a way that we, working together, can create these meaningful work products and work together to produce them for the people we serve and transform the system. So we've talked about the work product. Now in closing, I would like to give you a little bit of information about the delivery system. As we looked at the delivery system of work products for care coordination in our own community, this is what we found. If we focus on the person, you can have that 17-year-old pregnant female, she can have eight of these care coordinators. Because of the way the funding works, the cost for each one of them could easily reach $10,000, $20,000, $30,000. If you look at the contracts based on the amount of money spent versus how many people served. She could have eight care coordinators representing more than $100,000 and she still may not connect to prenatal care because it's not required in any of their contracts. And she may show up in the E.R. and have a low birth weight baby and I would tell you that has happened every day and many, many times. The most care coordinators we found in a client have been 15 and that's in a small analysis. So again, looking to our American business partners. They produce complex behavioral based results on an unbelievable scale across networks way beyond what the health and social service system does. And we need to model how they do it. And if we say that, oh, you know, our work with health care is so much more complicated, anybody who says that and believes it hasn't been through the Atlanta airport which, except for the last few weeks, generally often runs fairly well. So we created a hub partnering and looking at American business and our community which molded together seven agencies that provide care coordination under a $1 million local budget. What this network essentially did was create a central point of registration and quality and data collection for the community so that we could begin to limit duplication and have common quality measures across the community. If you're the specific agency reaching this pregnant person, the first thing due is check in with the community hub and they're not checking all your chart notes and a whole bunch of other things. They're tracking very basic information like the client's name and a couple of other modifiers and what specific work products you're producing. If there's systems, data bases and all kinds of different ways to do this. But it's not that challenging. The other is instead of just providing home visits or phone calls, everyone in this network is actually producing common measurements of quality. They are engaging a particularly at-risk population, confirming their receipt of evidence based education, they're confirming they connect to prenatal care and a final outcome such as low birth weight or other measures is used to look at the result. In this $1 million contract prior to initiating this and this was published, what was found was 19 -- in that $1 million contract, seven agencies, they were serving 19 women that were in the identified at-risk census track. Actually, they served many more women in the neighborhoods where the average cost of a home was more than $100,000. But they were not serving those most at risk in the measurements they were serving under were phone calls and process. New contract was begun, incentives were begun. We've learned a lot since this started. But 140 -- I want to make sure I say it right. 146 at-risk women were served. There was no duplication and payment was based on them connecting to prenatal care and measuring the results. At first the agencies were somewhat uncomfortable about this. Interestingly, two agencies that were not able to serve that neighborhood dropped out. Increasing the funding pool. The five other agencies actually got a raise. They've learned how to do this. It's part of their daily work now and I don't know that there's any major complaint and we're pretty excited about the results. This work has collaborated with a huge national network and definitely have to mention HRSA, and The Academy of Pediatrics and many others. There are communities in multiple parts of the country doing this. There's now 12 that are at some phase of development. Again, all we are all trying to do is within our own communities, whether it's diabetes, asthma, heart disease, pregnancy, immunizations we're trying to find those most at risk, treat them and measure. The shining star for this in the history of the public health system, I believe, is D.A. Henderson and the elimination of small pox. If you think of it in this context, what they had was the evidence based intervention of the Small Pox vaccine, they had a $2.4 million budget. Not for one county, for the world. Smallpox is gone. There's been a couple of cases where test tubes have tipped over but it's gone. Since 1980. And the biggest accomplishment there as an example, at least to us, is they found everybody. Everybody and they made sure that they got that intervention and no one was left aside. So where is the challenge? Certainly the programs are challenged to begin to make their services meaningful but many are doing it already and simply not being recognized. And I think -- I don't think that's the biggest part of the challenge, although it's there. Where I think the greatest challenge is to the funders and to the policy makers. If we were at the grocery store and we noticed our bill was three times higher than it had ever been before, we might look at what we purchased at the grocery store to figure out how to make that not happen the next time. Funders and policy makers need to know the cost per person served, including the administrative fee for care coordination. They need to know whether there's duplication of that service. They need to know that they're purchasing work products that have some basis of meaning for the individual served and they need to make sure that it doesn't avoid those most at risk. Currently, it does. Those most at risk take three -- can take three or four times more time to serve. If you only get so much money for -- it's not a -- your fiscal officer will tell you to avoid those individuals simply because they take too much time. Using an American business example, if you fix used cars, you have 100 cars to fix, you only have one price, would you try to fix the ones that had the most problems, that were the most broken and had the most issues? Absolutely not. You would find the easiest ones, pick them and make the most money. And think of the way measures currently within the system that may not as fully address or consider risk can work to drive us in the wrong direction. How does all of this -- how does all of this talk line up with previous directions given by wonderful institutions like the institute of medicine and others? I think it follows their guidance just fine. In the 1988 institute of medicine report, three guidelines were given for public health transformation. Assessment, assurance and policy change. We need to assess the situations and make sure we're not leaving behind anybody, find those most at risk. We need to assure that they receive the care and we need policy change to make sure we do that better and smarter and faster. I'm going to just say that these are steps that I hope your programs would have access to. How, if you want to become a model program, establishing your coalition, defining your conditions, finding those at greatest risk, building your bench measures and then building your contracts and this is the key part. Find bold funders. They're out there. They're out there within the department of health who is one of the first ones. They're out there in Medicaid. Medicaid managed care companies like unison and care source and others are actually leading the way in this regard. They're out there in terms of private funding like the Toledo community foundation and they're out there in public jobs and family services funding like Charlene Newman in Mansfield, Ohio who moved almost all of her contracts to results. Throw the switch and measure your results and make sure that things are happening, meaningful to people. This is a list of resources and the final slide, I would like to close for questions and though it may sound silly, I would like to vote these proceedings to my mom, Dorothy Redding, for she has certainly put the challenge forward to me and my siblings to try to be like her. And thank you.

>> Thank you, Dr. Redding. Now we'll have some comments from Rick Wilk. Are you still there? Rick?

>> Rick, break in whenever you get access and we'll move on with questions.

>> Right now we don't have any questions online unless you have any question in the room.

>> I think one thing about incentives that is really important not only for individuals but for agencies is it really helps if you start with new money. So you don't take -- you don't pull out their current pay, whether they be an individual or a program, you come up with something beginning to be new and that helps them learn how to operate in that kind of setting. Once they get good at it, you can actually move more of the financing related to incentives and the people who -- the agencies and the individuals doing well with that won't mind a bit because they'll actually make more money. So you start with new money. You make it fair. You've got to consider cash flow so, for example, for the pregnancy pathway, when the care coordinator finds and engages and does all of the paperwork on the at-risk patients, it's really a process item but a critical one. There's a payment. Recognizing the cash flow has to get started. When they connect, when they are confirmed to connect to prenatal care and this is written in the article that is made available through the resources here, when they have confirmed to connect to prenatal care, another payment is made. But to be honest, we're learning how to do this in Toledo, Richland County and other parts of the country are each doing this with their own flavor. But not in a way that's punitive, in a way that's forcing the agencies to change.

RICK WILK: Mark, I apologize. I could not hear you when you called for me so I'm glad to step in whenever you would like me to say a few words.

>> Rick, please go ahead.

>> OK. Well, I guess a few things I would like to share is that after hearing mark's -- what mark has shared, I think that we really have an opportunity and a strong need to identify those most at risk. And if we really want to impact health outcomes, I think we're going to have to spend more of our time, not all of our time but more time identifying those most at risk and of course, we're increasingly understanding the value of delivering evidence based services to those most at risk. I think it's critical, of course, to follow up to review, that delivery of the evidence based services, make sure they really are delivered and to -- I think we increasingly have to start looking at measuring health outcomes as challenging as that is. I think if we don't think of outcomes at least some of the time, we're not going to move closer to the ultimate goal. And I think that the thing that mark is sharing, which I think is very challenging for so many of us to consider doing is linking our -- looking to connect outcomes to payment. That is very challenging and I think any time you talk about money, funding, grants, it creates some challenges but I think mark has shared how this can be done and how it's working. I've seen other communities begin to play with this and it does get people's attention and it does get at least some focus on outcomes and I think until we start focusing on the outcomes, we're not going to be producing them in the way we would like. So I think trying to find ways to tie the contracting to the achievement of results, be the outcomes or other type of intermediate results, is extremely important. I guess the last thing I would share, in watching the reaction communities have to the -- these concepts, when Dr. Redding shares them and this is typically coalitions, not individual providers, it's at first challenging for many participants but I see typically a number of organizations will step up with great interest and in time, very often, we've been really bringing a coalition together because while this approach is quite bold, it really touches the heart of what we want to accomplish in health care which is to improve health outcome. And it brings different types of organizations together in ways that we're not used to working which, of course, presents some challenges but it also presentations some extraordinary opportunities.

>> Thank you, Rick. And I think Rick is an example of an individual within our health and social service system very committed to achieving health disparity and there are individuals throughout our health and social service system that want to see it change and want to see it work. And with love and kindness, we need to make -- we need to see that happen. Thank you, Rick.

>> You're welcome.

>> Thank you, Rick. We do have a couple of questions online. The first question is, what does it cost to provide service to those at greatest risk? You mentioned it takes three or four times more to serve them.

>> Well, interestingly, it takes much less than what you're paying right now. I mean, what you're paying -- if you take a care coordination contract and we are evaluating them in Ohio, it is easy to range anywhere from a couple of thousand dollars a year per persons served to as much as $20,000 to $30,000 per person. If you consider administrative costs and again, from the point of the governor, the senate, or the president of the United States or the legislature, you're paying as high as 30 to 40 times the current market value for care coordination. So if you examine it in those terms, if we had a system where the payment actually was focused on meaningful results for people, and it was at market value, it would be much less than being paid now. But to give a more specific example, at an extremely at-risk pregnant woman, for example, who is homeless and has behavioral health and domestic violence and even drug and alcohol issues, could easily be an expense of $1,500 to $2,000 per year of service to be fair to the agency and chasing her down at every step and going to court hearings and again, you know, we could go into detail into the complexity of that kind of case. Whereas a case of someone far less at risk may be in a fair payment might be in the range of $300 or $400. The payments would be made based on meaningful product deliverables through the span of that year and not in a yearly payment of $2,000. And so it is expensive because it takes time to just get in the door, to help provide education, to overcome barriers of insurance, of transportation. It's expensive. But the record low birth weight baby we found in Ohio was over $3,000 first year expenses alone and we know that special education and other issues outweigh that further down the road. So it's pennies on the dollar. Thank you. Good question.

>> The next question is a bit broader question. Would you say that most of the healthy starts have a good system in the state?

>> I would say that the one that I know, that I've read about the most is Mario German's program in New York city. And that is awesome. And that's one of the best models in the world. But I would say that although I've never gotten to meet Mario and I've never -- when I first saw his project I, thought he was one of the best examples, although he certainly is approached from a different angle, they are finding the women and people most at risk. They're assuring that they -- and remember, insurance isn't the same as assurance. They are assuring that people connect to evidence based intervention and they are measuring their results. And I think it's an awesome program. I think where every -- I would pick on my own profession. Every health and social service professional needs to tie the work products and the services it provides to dollars and to market value. And that is the assessment in the coming health care transformation, we need to assess what we're buying and for what price and begin to make sure that that is meaningful to the people who it is supposed to be all about. Good question. I think healthy start and others, too, there's many different programs that could help lead the way with this and certainly healthy start is one of them.

>> Sorry for the long answer.

>> No. No. No problem at all. Actually, to pick on your profession a little bit more, recruiting question, how do we get more physicians on board?

>> You know, the way care coordination -- I've got to admit, there are definitely physicians who connect with care coordination. But most -- our experienced physicians are in our services. From the waiting room through the office and the hospital, we're connected. But my grandpa used to go to your house if you got sick but we left that quite a while ago and we have left the care coordination business in some respects. What is interesting is North Carolina, for example, has started a Medicaid project showed substantially improved outcomes by challenging physicians to do more care

co-ordinations. As people don't connect to our care, we lose money. The other way that they're affected is physicians, just like care coordinators, they are penalized because they're paid based on time, not how sick the person is. So if I take in this homeless, pregnant 17-year-old and I would be looking after her baby, that's going to take me -- to provide good care and to do the right thing is going to take me a lot more time so I'm -- if we look at the business offices, physician offices, they have to limit the number of at-risk people they serve. What is fascinating from a policy point of view, if you build the incentives right, we would be tripping over ourselves to serve those most at risk. 5% of the population represents 50% of the cost. That 5% of the population is who we need to be at the door serving and there's many models to do it and the incentive structure should be built to support the physicians who against the financial system are serving those folks anyway and to make it doable. Especially as far as the prices have been, it's $36 for a pediatrician that is the Medicaid patient. That's what you get paid and you have overhead and other stuff and I'm not here to request more physician payment but my point is, incentives could be developed for physicians along the same lines and we could begin to develop a better system of care for those most at risk. Questions are awesome.

>> Question kind of related to your incentives which you already brought up. How do you work with agencies that each have their own measures, mandate the care coordination, often don't have incentives to work together? >> Another great question. Maybe I shouldn't say this but there's a feisty attorney in Mansfield, Ohio. LoelB. Miller. He's examined the federal contracts and examined the state contracts and he goes to a level of detail I've never seen before. And what he says is like the old Wendy's commercial of where is the beef? Where is the request from the leadership? If there is a leader in this country that wants to transform health care, create a request. It does not exist yet. If you examine the federal policy, if you examine then the way that that request turns into a contract, where is the request that we have to serve those most at risk? Where is the request that we have to assure that they connect to care? If you don't ask them to fix a certain part of your car, are they just going to fix it anyway? No. You've got to ask. And we use these -- the other part of this that's so critical T has to get to the details. It has to get to that person and their issues and the evidence based initiatives they need. If you use the percentage approach, what we're using now, get 770% of the lead kids or your worst outcomes are coming from the 5% that nobody touches. Who of us would have 70% of our lawn mowed or ask somebody to build 82% of our house? If we did, what part of our house would they build? What is exciting is direct services has the work products. We need the work products and care coordination, everything is there to do that. And you get what you pay for. And I guess all of this is not to say that there aren't model programs all over the place showing the system the way. It's just they are not being reimbursed for what they're doing. You know, any program that is actually reaching at risk and connecting them to care or any physician or provider who is doing this work should be supported more in doing it. Thank you.

>> Thank you. In reducing duplication of care coordination services, how do you ensure that a single provider has the needed experience to address all of the client's needs? For example, prenatal care management and mental care.

>> I think that's an excellent question and I think that's where some of the intervention needs to come in. There are good reasons for the client to have duplication of service. You know, they need a special diabetes nurse or they need a special behavioral health intervention like you just said. But the key is like a business, you know about that duplication. There's a purpose for the client and it's not just duplication. It's not just a bunch of people essentially doing the same thing. But what is interesting about care coordination in its most basic form is that there needs to be standards. There needs -- you know, you can't have somebody in somebody else's home that has a criminal background that would put you at risk as an agency for employing them. And that's just a cuff technical example, although there are some things on people's records that can be overcome that way, if you know what I'm saying. But you need to have standards in Ohio, and I've given the resource, the Ohio board of nursing has put their standards for community health workers who are generally people in part of the community served and their standards are online, you know, requiring background checks and other things so there needs to be basic standards. But if your focus is making sure problems are identified and people are connected to care, you can send out a pretty broad range of professionals to complete assessments they've been trained to do and then if you take the community health worker, for example, when they find out the person is pregnant or when they find out the person has aids or they find out the person has not had any shots in a long time, they bring that assessment back to the nurse or back to the other professionals, which is exactly how Alaska works and somebody at the appropriate level of training then makes decisions based on that assessment and they go out and see them. But I think what you're pointing to is quality. We need to have a strong sense of quality and there are examples, again, across the country to do that and good question. Very good.

>> More of a content related question. Can you speak more about the content of the timing of the community health aid?

>> Sure. It's listed in great detail online by the Ohio board of nursing. And you can have access to that. It needs to be modified depending on the outcomes that you're working on. But the core of the content is, for example, hipa, everybody needs to know it and it's tough to do when you're working in small communities and everybody talks to each other. How to write documents, the information that you collected and how to use whatever tools the program is using. And then interestingly, just like Alaska where we put a lot of our content was in the business of expelling myths. We provide training in basic anatomy, physiology, pharmacology but all at a level where it wouldn't restrict someone with a fifth grade education from taking the course. It has brought college credit. I think the other really exciting thing is it can become a career development so we've had now nursing and x-ray techs and L.P.N.s and others start in this kind of training in the community and move on and the other exciting thing is where most health professionals move out of the community once they become -- once they become a doctor or nurse practitioner, community health workers, when they become nurses and other professionals have been shown they actually stay in the community. But I think one other point that is important here, I spent a lot of 20 years working on community health workers and I believe in them, but I think -- I have seen community health worker programs with substantial funding that were not producing results. And they, like everybody else, needs to be responsible for -- I mean, it's not about community health workers. It's about the people they're serving. There are huge benefits to the community and everything else in that profession but our focus needs to be on the individuals and obviously the community health worker brings a strength of being able to get into homes that I certainly don't have access to and I have definitely seen that others don't. But the accountability still needs to be there. Thank you. And we have -- on our webpage, too, you're happy to -- I mean, you can ask us, bring any information. Most of our stuff is completely free or close to printing costs so -- and there's others we can direct you to.

>> Thank you. Actually, where can you find additional information on the fiscal model you referenced is structured?

>> I think the best example of that is the Columbia university voices article published a couple of years ago, and again, we are not a university center and I wish we had so many more publications but this is one that focused on the incentive model and the hub model and it's accessible under our website. Pages three and eleven are the ones particularly that highlight the funding model and then my email address is on there, too, so feel free to contact me and I would be happy to -- my work with this is primarily volunteer other than some consulting and expense related stuff and we're on a mission to do this together and so most of what is out there is not in any way proprietary or limited so --

>> Thank you. Do you have any questions in the room? No? OK. There is another question. What can programs do with the outcome data to influence policies?

>> Great question. Man. You know, that is the interesting thing about this. Us programs have got to do what you just said. We've got to show, and I know this sounds -- but we've got to show the policy makers that it can be done. Except the hardest challenge has been to get the funders to actually increase their accountability in the contract. The hardest part of this has been to get the funders to make this request. And I know that that sounds silly, but funders fund essentially constituents who get mad. And if they do it wrong, they can get really mad. And what is interesting is, there is a way, and we need a lot more time to discuss it. There's a way in a supportive way to actually help grow these agencies and grow the service system and care coordination and not make anybody mad unless they're absolutely not doing anything to help anybody, which it's OK if they're mad. But the large majority of them, it's possible. So we've got to do exactly what you said. Come up with meaningful benchmarks for the people that you serve that are measurable, that are accountable. Look at what you -- it costs you to produce them and this is obviously very timely so show what it costs for you to produce that product. Whether it was the person getting housing or food or clothing, whether it was prenatal related, diabetes related, behavioral health related and then come up with cost comparisons to show what would happen if you won't. And create your own production model of these specific services at risk people and what is being saved and I think what would be great would be to be some league of these funders, these bold funders that they're going out on the furtherest limb that I've seen anyone go. They're having the hardest time with this. Very good question. Please feel free to email me with other questions related to that.

>> OK. I really appreciate this question. I don't want to minimize the information technology. But I think it's really critical that it not be about that. It needs -- and you'll see why, hopefully why I'm saying this. What our focus needs to be is finding those people who need the help and connecting to them in care. What I've seen happen is everybody has created a whole structure but it's built around a data base and that all wasn't focused on serving the person. She's still not getting the prenatal care. What we're recommending to communities is that when they build this thing that they actually start with a paper system and again, people can do it however they want. I think if they're technically savvy and have the resources, most of these communities have very limited technology resources but -- so they start with a paper system and what that forces them to do is keep it really simple. So in richland county, when you turn in your bill, you don't turn in a whole bunch of stuff. You just turn in the benchmarks of this pathway and it worked fine in a paper structure. There's still a big part of the paper structure. Once the paper structure is together, then build the technology that does that and obviously it brings in a whole bunch more great things about it. So the other thing that looking at the strengths of technology can do is right now, in most situations, direct service and care coordination are separate from each other. The doctor doesn't even know that she has one care coordinator, let alone eight. And the doctor is on the phone trying to figure out how to get in touch with this person that doesn't have any phone and moves three times and gives up in frustration. You have a data system, which like Alaska, molds into a medical home model the care coordinations and I would say a medical home model and it molds two things together so you get online and you can see that oh, here is the care coordinator. I can communicate with her and get in touch with her that this lead level is 60 or whatever. It could be a substantial effect. And then the latest thing we're doing is -- that I think technology complements, the financial piece is what is most profoundly broken, we believe. So now, thanks to Joe mudra in richland county, one of the substantially bold funders, as the agencies put in their pregnancy pathway online, all they need to do to invoice is to hit a button and what is fascinating about the invoice is it's all related to meaningful results to the person. That's what you get paid for. So when we go trying to research our data, we don't actually have -- in most cases we don't have to look at the charts or even do a new report. The large majority of it is in the invoice. How many at-risk people we found, what barriers they had and what the birth weight of their baby was. So it actually creates this link between quality and financing and technology when it's well done can substantially make that possible, especially for small programs that usually can't afford it.

>> You mentioned policy. You can have people -- community outcome that is really the practices behind those outcomes.

>> I hear you. I think you could talk -- there could be a lot of detail related to that but if it's care coordination, if we went sort of right down the list, quality measurement, the first measure of quality would be, was the person at risk? In other words, were you serving somebody who lives in a $500,000 home who has lived -- whose chances of a low birth weight baby is 3%? One measure of quality is to make sure we're actually giving people services they need and that it's focused on somebody who needs it. The next would be in most of these care coordination approaches, there has to be health education component and that's got to be quality based. If you have somebody providing just off the cuff health education, I've seen some scary examples of that. And it needs to be -- that needs to be evidence based, it needs to be in a package and the person delivering it absolutely can be from the community or church or whatever but they need to be trained as to what they're delivering and they need to have whatever myths they're walking into it addressed. Then I think it's a measure of quality that you fully assess the patient and what their barriers to care are, things like language and transportation and culture and behavioral health and they were sent away from the doctor's office and they're afraid. And then a payment point for us, and possibly our most significant measure of quality for care coordination and fits with other national standards which really aren't utilized much but that they actually receive the care. We have people with 3,000 pages of chart notes that never actually connect to the service. And then we shouldn't hold care coordinators 100% responsible for all outcomes because they don't control that completely. But they certainly should measure the final outcome and look at it and it can be part of the payment structure as it is -- care coordinators that have normal birth weight babies in our system actually get -- the program and the coordinator get a higher payment. It's an incentive structure. It encourages them to get them to stop smoking and get the care they need.

>> A broader policy question. I'm just curious your take on this. You mentioned about focusing and just a minute ago you talked about focusing on those most in need of making sure their needs were met first. Since last August there have been some interesting arguments about Medicaid and the participant of that or one of the participants was a letter that went out from Medicaid services to states saying you may no longer expand the level of -- increase the percentage of poverty level for programs unless you can show that 95% of those eligible for Medicaid are, in fact, being served. It sounds similar to what you're saying. Saying in the community you want to be sure that those who are in the back of the housing project, the ones who are most difficult to find are being served. Well, we could argue that that is what the federal Medicaid program is doing now. However, the push back from states have been that there are others in need and what you are doing in effect. Because we can never get to that 5%, you are in effect preventing us from serving others who we could get to. How do you deal with that issue?

>> That's a beautiful question. Now, and I want to focus on the last thing that you quoted or said is that there are people that are not served but we're never going to reach them so we need to move on to others. And the point being there, that is what has been said -- I can't tell you the struggles some of these -- we've got leaders, we call them community change agents and developed through HRSA in substantial part that are pounding on their communities and dealing with these issues right on the front lines. And what they so often run into is they begin to focus on at-risk, they find the at-risk population but everybody says we tried to serve those people and we can't so we're moving on. And essentially there, the individuals that will not utilize the service the way we have put it forward, you know, in other words, we've essentially put forward a store front of health care. It's like building 1,000 Wal-Marts or whatever. The basis of the store front is built by not people in poverty but built by the rest of us who have cell phones and are comfortable going to doctors. And then if people don't connect to our store front, we blame it on them and we say, oh, well, you know, we put up this beautiful store front and then the primary incentives in most of the contracts is they not use it. There's greater payments to those who provide the system of care if people actually don't shop at Wal-Mart which is another huge philosophical problem with the structure. So within that group that you just quoted that just can't be served, they can be served. And they can be reached. But different strategies are needed and strategis that can reach people in poverty, Alaska was faced with the same thing in the 1940's. Bodies were piling up from the epidemic and they could not figure out -- whole villages were disappearing. 1946 or 1947. Nurses had no idea what to do and it was overwhelming. So they went not back to Washington, they went to the communities and they asked and they said, look. Is there everybody here that can find these people at risk and get them to connect to care? We've done everything else we can and the women came forward from the community and the T.B. epidemic was gone in a year. So my point is that you're describing an ethical process where we leave behind the most significantly at-risk population and I have got to admit, I've got to support the department of Medicaid in this if they're doing that because if the services are limited and we have a four or five fold difference in outcomes, we've got to reach those who need the care the most. One final thing, I think like childhood immunizations, you would want to make sure everybody got childhood immunizations on this thing about the people at risk, it's not saying that they should have more care than everybody else. No. It just needs to be equal. If we understand poverty and where they're living in the back of a rural house trailer or urban center and somebody builds the system who understands what they're fighting, we're just got to make sure they get the same packages and it's going to take more work that my kids get. Low birth rate is 3% in my community and it's uncomfortable of being a couple of miles where it's 24%. Very good question. Wow. And I think an example of how us as a system can make an excuse for not doing the work that needs to be done. Very good. My dad is a minister so it comes honestly. You know what? To me what is so exciting about this is the opportunity that we have. We have the goods. Now we just have to get them delivered and we need to build an accountable structure to make sure that happens. If the president, if the Congress, if the senate would simply request that those at risk be identified and connected to care, it can be done. You have the resources, you have the data, you know where they are and there's 1,000 examples of strategis that can engage those forgotten people and help them connect. And affect generations ongoing. Thank you. It this our close or -- no?

>> Do we have any other questions in the room? There are no more questions online.

>> I appreciate so much the questions and the engagement and I really appreciated this dialogue and learned a lot. Thank you.

>> On behalf of the division of healthy start, I would like to thank Dr. Reding and other audience. I would like to thank our contractors who made this work. We encourage you to let your colleagues know about the website. We look forward to your participation in future web casts.